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SPONTANEOUS PERFORATION OF THE STOMACH.

6.

Hence these cases may be easily mistaken for those of irritant poisoning. The principal facts observed with regard to this formidable disease are the following-1. It often attacks young women from eighteen to twentythree years of age. 2. The preceding illness is extremely slight; sometimes there is merely loss of appetite, or a capricious appetite, with uneasiness after eating. 3. The attack commences with a sudden and severe pain in the abdomen, generally soon after a meal. The pain usually comes on gradually in irritant poisoning, and slowly increases in severity 4. Vomiting, if it exists at all, is commonly slight, and is chiefly confined to what is swallowed. There is no purging: the bowels are generally constipated. In irritant poisoning the vomiting is usually severe, and purging is seldom absent. 5. The person dies commonly in from eighteen to thirty-six hours: this is also a usual period of death in the most common form of irritant poisoning, i. e. by arsenic; but in no case yet recorded has arsenic caused perforation of the stomach within twenty-four hours, and it appears probable that a considerable time must elapse before such an effect could be produced by this or any irritant. In perforation from disease the symptoms and death are clearly referable to peritonitis. 7. In the perforation from disease the aperture is commonly of an oval or rounded form, about half an inch in diameter, situated in or near the lesser curvature of the stomach, and the edges are smooth. The outer margin of the aperture is often blackened, and the aperture itself is funnel-shaped from within outwards; i. e., the mucous coat is the most removed, and the outer or peritoneal coat the least. The coats of the stomach, round the edge of the aperture, are usually thickened for some distance; and when cut they have almost a cartilaginous hardness. These characters of the aperture will not alone indicate whether it is the result of poisoning or disease; but the absence of poison from the stomach, with the want of other characteristic marks of irritant poisoning, would enable us to say that disease was the cause. Besides, the history of the case during life would materially assist us in our judgment. The great risk on these occasions is that the effects of disease may be mistaken for those of poisoning; for we are not likely to mistake a perforation caused by irritant poison for the result of disease. Notwithstanding the well-marked differences above described, it is common to meet with cases of imputed poisoning where death has really occurred from peritonitis following perforation. A case of this kind will be found elsewhere recorded. (Guy's Hosp. Rep., 1851, p. 226.) In another the body was exhumed after several months' burial, and the stomach was found perforated from disease in the usual situation.

Spontaneous or Gelatinized Perforation.-The stomach is occasionally subject to a spontaneous change, by which its coats are softened, and give way, generally at the cardiac or greater end. As the effusion of the contents of the organ in such a case never gives rise to peritoneal inflammation, and no symptoms occur prior to death to indicate the existence of so extensive a destruction of parts, it is presumed to be a change in the dead body, and the coats of the stomach are supposed to undergo a process of solution or digestion. It is commonly attributed to the solvent action of the gastric juice, the spleen, diaphragm, and other viscera being sometimes softened. Wilkes states that this post-mortem or cadaveric perforation of the stomach is so rare a condition that it is not met with once in five hundred cases. In the last two cases in which it was observed by him, one patient had died from albuminuria, and the other from headaffection; but in neither of these could there be found any peculiarities regarding their food, the time of the last meal, or the state of the bodies

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to account for the spontaneous destruction of the coats of the stomach. In January, 1845, the author met with an instance of this perforation in a child between two and three years of age. It was seized with convulsions, became insensible, and died twenty-three hours afterwards. After death, the greater end of the stomach was found destroyed to the extent of three inches; and the edges were softened and blackened. There was no food in the stomach, and nothing had passed into this organ for thirtytwo hours before death. It was therefore impossible to ascribe death to the perforation or the perforation to poison. (Med. Gaz., vol. 36, p. 32.) An inspection of the body, with a general history of the case, will commonly suffice to remove any doubt in forming an opinion whether the extensive destruction, so commonly met with, has or has not arisen from poison. Thus in a post-mortem perforation, the aperture is generally situated in that part of the stomach which lies to the left of the cardia; it is very large, of an irregular form, and ragged and pulpy at the edges, which have the appearance of being scraped. The mucous membrane of the stomach is not found inflamed. There is occasionally slight redness, with dark brown or almost black lines (striæ) in and near the dissolved coats, which have an acid reaction. It can only be confounded with perforation by the action of corrosives; but the well-marked symptoms during life, and the detection of the poison after death, together with the changes in the throat and gullet, will at once indicate the perforation produced by corrosive poison. Pavy has shown that after death the gastric juice dissolves the stomach. [Dr. Hartshorne comments on the vital importance, in cases of this kind, of the post-mortem being conducted by an experienced, thoroughly-trained examiner, of sufficient judgment to fully and distinctly understand the appearances herein before indicated, and shows how valueless the examination would be if made by ignorant and untrained practitioners. He cites the case of John Hendrickson, Jr., convicted by this latter class of evidence, as exposed by Dr. C. Lee (Am. Jour. Med. Sci., October, 1885, p. 447), and insists that medical evidence, whether as to anatomical appearances, odor and color, form, or microscopical inquiry, is and should, in the nature of things, be restricted to the very few experts who could be found competent to give reliable evidence in these cases.

Prof. Reese claims that Chap. XI., supra, regarding chemical analysis in establishing the proof of poisoning, is most important and valuable, and says that it is very dangerous in a case of life and death to rely either upon symptoms or autopsic appearances, or even upon both, as affording positive proof of poison. While unwilling to claim that the chemical evidence is always indispensable to prove the administration of poison in certain cases where chemical detection is impossible, yet in these exceptional cases the other two factors-symptoms and the anatomical lesions— as well as the moral circumstances of the case, should be so positive and unequivocal as to leave no shadow of doubt.

Wharton and Stillé, in commenting on this subject, say: "These verifications (the symptoms and the autopsy) once established, and a harmony. between the lesions shown by the physician and physiologist, and the substance discovered by chemical analysis being settled, then and only then can the conclusion be reached that death was due to poison:" Vol. II., p. 287, 1873.]

96

SULPHURIC ACID-SYMPTOMS.

CORROSIVE AND IRRITANT POISONS.

CHAPTER VII.

SULPHURIC ACID, OR OIL OF VITRIOL.-NITRIC ACID, OR AQUA FORTIS.-HYDROCHLORICACID, OR SPIRIT OF SALT.-SYMPTOMS.-APPEARANCES AND ANALYSIS.-NITRO-HYDROCHLORIC ACID OR AQUA REGIA.

-

SULPHURIC ACID, OR OIL OF VITRIOL.

Symptoms. When this poison is swallowed in a concentrated form, the symptoms produced come on either immediately or during the act of swallowing. It has, however, been taken in mistake for a magnesian mixture, without the mistake being discovered till after the lapse of some time. There is violent burning pain, extending down the throat and gullet to the stomach, and the pain is often so severe that the body is bent. There is an escape of gaseous and frothy matter, followed by retching and vomiting; the latter accompanied by the discharge of shreds of tough mucus and of a liquid of a dark coffee-ground color, mixed with blood. The vomited matters may contain shreds of mucous membrane from the gullet and stomach, and even portions of the muscular tissue of the former. These may form complete casts of some portion of the gullet or stomach. The mouth is excoriated, the lining membrane and surface of the tongue white, or resembling soaked parchment; and in one instance the appearance of the mouth was as if it had been smeared with white paint. After a time the membrane acquires a gray or brownish color; the mouth is filled with a thick viscid substance consisting of saliva, mucus, and the corroded membrane; this renders speaking and swallowing dif ficult. If the poison has.been administered by a spoon, as in infants, or the phial containing it has been passed to the back of the throat, the mouth may escape the chemical action of the acid, and a child will not always scream under such circumstances. Around the lips and on the neck may be found spots of a brown color from the spilling of the acid and its action on the skin. There is great difficulty of breathing, owing to the swelling and excoriation of the throat and larynx; and the countenance has from this cause a bluish or livid appearance. The least motion of the abdominal muscles is attended with increase of pain. The stomach is so irritable that whatever is swallowed is immediately ejected, and the vomiting. is commonly violent and incessant. The matters first vomited generally contain the poison: they are acid, and, if they fall on a lime-stone pavement, there is effervescence; if on colored articles of dress, the color is sometimes altered to a red or yellow, or it is entirely discharged and the texture of the stuff destroyed; on a black cloth dress, the spots produced by the concentrated acid are reddish-brown, and remain moist for a considerable time. After a time there is exhaustion, accompanied by great weakness; the pulse becomes quick, small, and feeble; the skin cold, mottled, and covered with a clammy sweat. There is generally great

APPEARANCES AFTER DEATH-FATAL DOSE.

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thirst, with obstinate constipation, and should any evacuations take place they are commonly either of a dark brown or of a leaden color, and in some instances almost black from an admixture of altered blood. There are sometimes convulsive motions of the muscles, especially those of the face and lips. The countenance, if not livid from obstructed respiration, is pale, and expressive of great anxiety and intense suffering. The intellectual faculties are quite clear; and death usually takes place very suddenly, in from eighteen to twenty-four hours after the poison has been taken. Sulphate of indigo produces similar symptoms. The vomited matters are, however, bluish-black.

Appearances after Death.-The appearances met with in the body of a person who has died from the effects of this acid vary, according to whether death has taken place rapidly or slowly. Supposing the case to have proved rapidly fatal, the membrane lining the mouth may be found white, softened, and corroded. The mucous membrane of the throat and gullet is commonly found corroded, having a brown-black or ash-gray color, and blood is effused in patches beneath it. The corroded membrane of the gullet is occasionally disposed in longitudinal folds, portions of it being partly detached. The stomach, if not perforated, is collapsed and contracted. On laying it open, the contents are commonly found of a dark brown or black color and of a tarry consistency, being formed in great part of mucus and altered blood. The contents may or may not be acid, according to the time the patient has survived, and the treatment which has been adopted. On removing them, the stomach may be seen traversed by black lines, or the whole of the mucous membrane may be stained black or of a dark brown color. On forcibly stretching the coats, the red color indicative of inflammation may be sometimes seen in the parts beneath, or surrounding the blackened portions.

When the stomach is perforated, the coats are softened, and the edge of the aperture is commonly black and irregular. In removing the stomach, the opening is liable to be made larger by the mere weight of the organ. The contents do not always escape; but, when this happens, the surrounding parts are attacked by the poison. The spleen, the liver, and the coats of the aorta have been found blackened and corroded by the acid, which had escaped through the perforation. In rare cases the lining membrane of the aorta has been found strongly reddened. When a person has survived for eighteen or twenty hours, traces of corrosive and inflammatory action may be found in the small intestines. In one case the mucous membrane of the ileum was corroded. The interior of the windpipe, as well as of the bronchial tubes, has also presented marks of the local action of the acid. The acid has thus destroyed life without reaching the stomach. A remarkable instance in which the poison penetrated into and destroyed both lungs has been reported. (Med. Gaz., vol. 45, p. 1102.) It is important for a medical witness to bear in mind that the mouth, throat, and gullet are not always found in the state above described. Ogle met with a case in which the tongue was but slightly affected.

Fatal Dose. The dangerous effects of sulphuric acid appear to arise rather from its degree of concentration than from the absolute quantity taken. The quantity actually required to prove fatal must depend on many circumstances. If the stomach is full when the poison is swallowed, the action of the acid may be spent on the food and not on the stomach; and a larger quantity might then be taken than would suffice to destroy life if the organ were empty. The smallest quantity which is described as having proved fatal was in the following case: Half a teaspoonful of concentrated sulphuric acid was given to a child about a year

The

old by mistake for castor oil. The usual symptoms came on, with great disturbance of breathing; and the child died in twenty-four hours. quantity here taken could not have exceeded forty drops. (Med. Gaz., vol. 29, p. 147.) It is, however, doubtful whether this small quantity would have proved fatal to an adult. The smallest fatal dose which Christison states he has found recorded is one drachm; it was taken in mistake by a young man, and killed him in seven days: ON POISONS. Even when diluted, the acid will rapidly destroy life. A man swallowed, on an empty stomach, six drachms of the strongest acid diluted with eighteen drachms of water. He suffered from the usual symptoms, and died in two hours and a half. (Med. Times and Gaz., 1863, 1, p. 183.)

Fatal Period. The average period at which death takes place in cases of acute poisoning by sulphuric acid is from eighteen to twenty-four hours. The shortest case recorded occurred to Rapp. A man, æt. 50, swallowed three ounces and a half of concentrated sulphuric acid; he died in three quarters of an hour. (Gaz. Med., Dec. 28, 1850.) On the other hand, there are numerous instances reported in which the poison has proved fatal, from secondary causes, at periods varying from one week to several months, and even years.

Chemical Analysis.-If the acid is in a concentrated state it possesses these properties: 1. Wood, sugar, or other organic matter plunged into it, is speedily carbonized or charred, either with or without the application of heat. 2. When boiled with wood, copper-cuttings, or mercury, it evolves fumes of dioxide of sulphur; this is immediately known by the odor, as well as by the vapor first rendering blue, and then bleaching, starch-paper dipped in a solution of iodic acid. 3. When mixed with an equal bulk of water, great heat is evolved.

Sulphuric acid when diluted does not carbonize organic substances. If, however, a glass rod be dipped in the diluted acid, and a mark be made with this upon writing-paper, and the paper be then gently dried before a fire, a black mark will be left wherever the acid has touched the paper. This test is applicable to organic liquids containing sulphuric acid. The best reagent for its detection is a solution of barium—either the nitrate or the chloride of barium. Having ascertained by test-paper that the suspected liquid is acid, and contains a free mineral acid (see below), we add to a portion of it a few drops of nitric acid, and then a solution of barium salt. If sulphuric acid is present, a white precipitate of sulphate of barium will fall down: this is insoluble in all acids and alkalies. If the precipitate is collected, dried, and heated to full redness for some minutes in a platinum crucible, or in a folded piece of platinum foil, with five or six parts of charcoal powder, it will, if a sulphate, be converted into sulphide of barium. To prove this, we add to the calcined residue hydrochloric acid, at the same time suspending over it a slip of filtering paper moistened with a solution of acetate of lead. If the precipitate obtained is a sulphate, the gas evolved will be sulphuretted hydrogen, known by its odor, and by its turning a salt of lead of a brown color.

Cyanide of potassium may be used as a reducing agent in place of charcoal, in a proportion of one part to three parts of the sulphate of barium. The mixture should be heated to fusion in a reduction-tube. On breaking the glass when cold, and laying the incinerated residue on paper or card wetted with a salt of lead, a brown stain indicative of sulphide of lead is produced; or the residue may be dissolved in water, and a solution of acetate of lead added to it.

[A very delicate test for dilute sulphuric acid is veratria, which, when introduced in small quantity, and evaporated to dryness, produces a beautiful purple color: Reese.]